# Patent

## Title
Controlling giardiosis

## Abstract

The present invention relates to the use of nifurtimox for the treatment of giardiosis, in particular in dogs and cats.

## Background
The present invention relates to the use of nifurtimox for the treatment of giardiosis, in particular in dogs and cats.
The efficacy of nitro-heterocyclic compounds against protozoan diseases is known (1).
The Protozoa include single-nuclear organisms whose basic structure is a eukaryotic cell. The more precise systematics, however, reveal large differences in habit, morphology and the biochemical metabolism of the individual strains, classes, genera and species. This is why chemicals, depending on their target and active principle, usually do not act equally well against all Protozoa, but only against specific groups of Protozoa (2, 3, 4).
To date, the efficacy of nifurtimox has only been described against protozoan species of the genus Trypanosoma, e.g. Trypanosoma brucei and Trypanosoma cruzi (5). Trypanosoma have a flagellum which originates on the basal body (“kinetosome”) and, in conjunction with the basal body, develops an undulating membrane. Parasites with this basic morphological type belong, within protozoan systematics, to the order Kinetoplastida. Trypanosoma grow predominantly in the blood plasma and are transmitted by blood-sucking arthropods. These pathogens cause Chagas disease (“trypanosomiasis”) of humans. nifurtimox is currently almost the only compound which is active against these pathogens. This activity is probably based on inhibiting the enzyme trypanothione reductase, a specific trypanosomal enzyme. This enzyme is absent in other protozoan pathogens.
The activity of nifurtimox against Trichomonadida is described in a patent application filed in parallel.
Giardiosis is an infectious disease which is caused by flagellated, unicellular parasites of the genus Giardia. This genus belongs to the order Diplomonadida. Its most important representative is Giardia lamblia (syn. Giardia intestinalis, Giardia duodenalis). The percentage of positive dog and cat samples is up to 50% worldwide, and 2-7% in Central Europe. Infection leads to persistent diarrhoea and in some cases bloody faeces, caused by inflammation of the duodenum and jejunum, especially in very young animals up to half a year old. Chronic disease can lead to presently delayed growth (6).
More than 7 genotypes (A-G) have been described for Giardia isolates. Genotypes A+B are infectious for humans and may also occur in cats, dogs, beavers, sheep, calves, horses, pigs and monkeys. This is why the disease is considered to be a “zoonosis”: Humans can become infected with cysts from dogs and cats via contaminated drinking water. Giardia infections are worldwide among the most frequent causative agents of what are known as water-borne outbreaks in humans (7).
Infection is usually via the cyst form by the oral route, by contaminated drinking water or infectious faeces. In the gut, so-called trophozoites hatch from the cyst. A trophozoite measures 11-17×7-11 μm, contains two nuclei and 8 flagella. In contrast to other groups of flagellated parasites, Giardia trophozoites do not penetrate intracellularly into epithelia. Trophozoites have an acetabulum, with the aid of which they can anchor themselves on the outside of the gut lumen of humans, monkeys, pigs, dogs and cats, where they multiply by division. Massive attack blocks and modifies the absorbing gut surface and in some cases causes bloody diarrhoea. Cysts are again formed in the appendix and are again excreted via the faeces with a prepatency time of 5-16 days after the primary infection. Cysts can be excreted over a period of 4-5 weeks and remain infectious over several weeks (8, 9).
There are substantial morphological and biochemical differences to the order Kinetoplastida: Diplomonadida have 8 flagella and two nuclei, but there are no mitochondria and no Golgi complex, and no intracellular stages are known during the life cycle. In contrast to Trypanosoma, surface proteins of Giardia do not have a GPI anchor (10).
In dogs and cats, a therapy with metronidazole (Clont®, Flagyl®, Elyzol®) at a dosage of 12.5-22 mg/kg bodyweight b.i.d. over 5 days is currently recommended. (11): Metronidazole and other 5-nitroimidazoles are activated by the enzyme pyruvate-ferredoxin oxidoreductase to form free nitro radicals, which then engage with the parasite DNA metabolism. This is why ipronidazole (Ipropan®, 126 mg/l drinking water over 7 days) and tinidazole (Fasigyn®, 44 mg/kg bodyweight over 3 days) are also suitable for the therapy of giardiosis in dogs (12, 13).
Substances which are recommended from the group of the benzimidazoles are mebendazole, albendazole or fenbendazole (oral over 3 days). Benzimidazoles interfere with the polymerization of the microtubuli by binding to the subunit of β-tubulin. Microtubuli are important cytoskeleton elements of the parasite which stabilize in a particular manner the acetabulum of the trophozoites.
Substances which are employed in the human sector include antibiotics (for example paramomycin, 25-35 mg/kg/day in three dosages for 7-10 days), quinacrin and furazolidon (100 mg t.i.d. 7 days long) or nitazoxanid (500 mg b.i.d. for 3 days) (14).
Many of these classes of active substances have been employed for a long time for the treatment of giardiosis, and the development of resistance has been detected for most and has lead to documented failures in the treatment. The development of novel active substances and treatment concepts is therefore a necessity (15).
Surprisingly, we have now found that nifurtimox has an activity against Giardia species. This activity has not been described to date. The activity is directed at the gut-pathogenic stages and prevents cyst formation.
The invention therefore relates to:

    the use of nifurtimox for the preparation of pharmaceuticals for the treatment of disease caused by Giardia species.


nifurtimox is the compound of the formula (I):




If appropriate, the use in the form of customary pharmaceutically acceptable salts is also suitable. If appropriate, the use of hydrates or other solvates of the active substances or, if appropriate, of their salts is furthermore also suitable.
The use can be both prophylactic and therapeutic. The activity is directed against different stages of the pathogen; in particular, nifurtimox acts against the gut-pathogenic stages and prevents cyst formation.
Of particular importance among the Giardia species are Giardia lamblia (syn. Giardia intestinalis, Giardia duodenalis), Giardia bovis and Giardia caprae. The species listed here are frequently used synonymously for one another and display little host specificity.
Organisms which are treated in accordance with the invention are animals (carnivores and wild animals), preferably mammals such as, for example, horses, pigs, rabbits, in particular dogs or cats.
According to one embodiment, the preferred treatment among mammals is the treatment of wild animals and in particular of carnivores (dogs, cats).
Humans, too, are suitable for treatment, since humans can become infected with the animal-pathogenic Giardia species via contaminated drinking water.
Giardiosis is found mainly in young animals, preferably aged 3-10 weeks, and causes severe diarrhoea and reduced weight gain.
The active substances are applied directly or in the form of suitable preparations via the enteral, parenteral, dermal route.
The enteral administration of the active substances is effected for example orally in the form of powders, suppositories, tablets, capsules, pastes, drinks, granules, drenches, boluses, medicated feed or drinking water. Dermal administration is effected for example in the form of dipping, spraying, bathing, washing, pouring on and spotting on and dusting. Parenteral administration is effected for example in the form of an injection (intramuscular, subcutaneous, intravenous, intraperitoneal) or by implants.
Suitable preparations are:

    solutions such as solutions for injection, oral solutions, concentrates for oral administration after dilution, solutions for use on the skin or in body cavities, pour-on and spot-on formulations, gels;
    emulsions and suspensions for oral or dermal administration and for injection; semi-solid preparations;
    formulations in which the active substance is incorporated in an ointment base or in an oil-in-water or water-in-oil emulsion base;
    solid preparations such as powders, premixes or concentrates, granules, pellets, tablets, boluses, capsules; aerosols and inhalers, active-substance-containing shaped articles.


Solutions for injection are administered for example intravenously, intramuscularly and subcutaneously.
Oral solutions are administered directly. Concentrates are administered orally after previously having been diluted to the use concentration.
Solutions for use for application to the skin are trickled on, painted on, rubbed on, splashed on, sprayed on or applied by dipping, bathing or washing.
Gels are applied to or painted onto the skin or introduced into body cavities.
Pour-on and spot-on formulations are poured onto or spotted onto limited areas of the skin, the active substance either penetrating the skin and acting systemically or distributing on the body surface.
Emulsions are either of the water-in-oil type or of the oil-in-water type and can be applied orally, dermally or as injections.
Suspensions can be applied orally, dermally or as an injection.
Semi-solid preparations can be administered orally or dermally. They differ from the above-described suspensions and emulsions merely by the fact that they are more viscose.
To prepare solid preparations, the active substances are mixed with suitable carriers, if appropriate with addition of adjuvants, and formulated as desired.
Especially preferred in accordance with the invention is oral administration, and tablets are especially preferred among the usual oral use forms.
All the abovementioned pharmaceutical forms, the additives and adjuvants to be used and the preparation of these pharmaceutical forms are known in principle to the skilled worker.
The active substances can exist in combination with synergists or with further active substances. Further active substances which may be mentioned are:
Coccidiostats such as robenidine or amprolium, in some cases in combination with folic acid antagonists (for example pyrimethamin, epiroprim, trimetoprim); antibiotics such as, for example clindamycin, paramomycin or spiramycin; sulfonamides such as, for example, sulfadimethoxin, sulfadimidin, sulfadiazin; anthelmintics such as, for example, cyclic depsipeptides (for example emodepside, PF1022A), amidine derivatives (tribendimidine, amidantel, bay d 9216), praziquantel or benzyl benzoate.
For a long-time treatment effect, it is recommended to, disinfect regularly as part of the animal-keeping routine.
Anthelmintics, in particular cyclic octadepsipeptides such as PF1022A or emodepside are suitable for controlling nematode infections in humans and animals (16). Here, all economically important nematodes in the gastrointestinal tract, including in dogs, are destroyed. It is also known that, in the case of nontreatment of the animals, the immune response (GALT=gut-associated-lymphoid-tissue) is directed against the worms (17). This is called the Th2 response of the immune system. In the case of noninfection, the immune response is normally balanced, i.e. the antagonist of the Th2 response, which is called the Th1 response, which is directed against Protozoa, viruses and bacteria, is just as pronounced as the Th2 response.
If an infection with nematodes, for example an infection with hookworm, roundworm or whipworm, is present in the animal in question, for example in the dog, then the balance is adversely affected, and the result is a predominant protozoan infection in the gut, caused, for example, by Giardia species. If the nematode infection is now overcome by suitable anthelmintics, the defense against Giardia species is enhanced indirectly, by allowing the Th1 response to act against these Protozoa. In the combination nifurtimox plus anthelmintics, the nifurtimox will now be able to exert better control of the Giardia infection, since the latter is already partly contained as the result of the Th1 response, which is indirectly enhanced as the result of the nematode control, i.e. the number of parasites in the gut is already reduced.
In accordance with the preferred embodiment, nifurtimox is employed in combination with anthelmintics.
Anthelmintics which are preferably employed are 24-membered cyclodepsipeptides (cyclooctadepsipeptides). The following may be mentioned:
Compounds of the Formula (IIa)




in which

    Z represents hydrogen, N-morpholinyl, NH2, mono- or dimethylamino.


Moreover, compounds of the following formula (IIb) may be mentioned:




in which

    R1, R2, R3, R4 independently of one another represent hydrogen, C1-C10-alkyl or aryl, in particular phenyl, which are optionally substituted by hydroxyl, C1-C10-alkoxy or halogen.


The compounds of the general formula (IIb) are known and can be obtained by the processes described in EP-A-382 173, DE-A 4 317 432, DE-A 4 317 457, DE-A 4 317 458, EP-A-634 408, EP-A-718 293, EP-A-872 481, EP-A-685 469, EP-A-626 375, EP-A-664 297, EP-A-669 343, EP-A-787 141, EP-A-865 498, EP-A-903 347.
The cyclic depsipeptides with 24 ring atoms also include compounds of the general formula (IIc)




in which

    R1a, R2a, R11a and R12a independently of one another represent C1-8-alkyl, C1-8-haloalkyl, C3-6-cycloalkyl, aralkyl, aryl,
    R3a, R5a, R7a, R9a independently of one another represent hydrogen or a straight-chain or branched C1-8-alkyl, each of which can optionally be substituted by hydroxyl, C1-4-alkoxy, carboxyl,






carboxamide,





imidazolyl, indolyl, guanidino, —SH or C1-4-alkylthio, and which furthermore represent aryl or aralkyl, each of which can be substituted by halogen, hydroxyl, C1-4-alkyl, C1-4-alkoxy,

    R4a, R6a, R8a, R10a independently of one another represent hydrogen, straight-chain C1-5-alkyl, C2-6-alkenyl, C3-7-cycloalkyl, each of which can optionally be substituted by hydroxyl, C1-4-alkoxy, carboxyl, carboxamide, imidazolyl, indolyl, guanidino, SH or C1-4-alkylthio, and represent aryl or aralkyl, each of which can be substituted by halogen, hydroxyl, C1-4-alkyl, C1-4-alkoxy, and their optical isomers and racemates.


Preferred compounds of the formula (IIc) are those in which

    R1a, R2a, R11a and R12a independently of one another represent methyl, ethyl, propyl, isopropyl, n-, s-, t-butyl or phenyl, each of which is optionally substituted by halogen, C1-4-alkyl, OH, C1-4-alkoxy, and represent benzyl or phenylethyl, each of which can optionally be substituted by the radicals mentioned for phenyl;
    R3a to R10a have the abovementioned meanings.


Especially preferred compounds of the formula (IIc) are those in which

    R1a, R2a, R11a and R12a independently of one another represent methyl, ethyl, propyl, isopropyl or n-, s-, t-butyl,
    R3a, R5a, R7a, R9a represent hydrogen, straight-chain or branched C1-8-alkyl, in particular methyl, ethyl, propyl, i-propyl, n-, s-, t-butyl, each of which can optionally be substituted by C1-4-alkoxy, in particular methoxy, ethoxy, imidazolyl, indolyl or C1-4-alkylthio, in particular methylthio, ethylthio, furthermore represent phenyl, benzyl or phenethyl, each of which can optionally be substituted by halogen, in particular chlorine.
    R4a, R6a, R8a, R10a independently of one another represent hydrogen, methyl, ethyl, n-propyl, n-butyl, vinyl, cyclohexyl, each of which can optionally be substituted by methoxy, ethoxy, imidazolyl, indolyl, methylthio, ethylthio, furthermore represent isopropyl, s-butyl, and furthermore represent optionally halogen-substituted phenyl, benzyl or phenylethyl.


The compounds of the formula (IIc) can also be obtained by the processes described in EP-A-382 173, DE-A 4 317 432, DE-A 4 317 457, DE-A 4 317 458, EP-A-634 408, EP-A-718 293, EP-A-872 481, EP-A-685 469, EP-A-626 375, EP-A-664 297, EP-A-669 343, EP-A-787 141, EP-A-865 498, EP-A-903 347.
A very especially preferred depsipeptide which may be mentioned is the compound PF 1022, which is known from EP-A 382 173; it is the compound of the formula (IIa) in which both substituents Z represent hydrogen. PF 1022 therefore has the following formula (IId):




Further preferred depsipeptides are compounds which are disclosed in the PCT application WO 93/19053, which are compounds of the formula (IIa)
in which


    Z represents N-morpholinyl, NH2, mono- or dimethylamino.


Very especially preferred among these compounds is the depsipeptide emodepside (PF 1022-221). This is the compound of the formula (IIa) in which both radicals Z represent the morpholinyl radical. The INN emodepside represents the compound with the systematic name: cyclo[(R)-lactoyl-N-methyl-L-leucyl-(R)-3-(p-morpholinophenyl)lactoyl-N-methyl-L-leucyl-(R)-lactoyl-N-methyl-L-leucyl-(R)-3-(p-morpholinophenyl)lactoyl-N-methyl-L-leucyl. Emodepside is described in WO 93/19053 and has the following formula:




Depending on their structure, the abovementioned active substances which are suitable for the combination may be present in stereoisomeric forms or as stereoisomers, for example as enantiomers or racemates. Both the stereoisomer mixtures and the pure stereoisomers can be used in accordance with the invention.
The following may furthermore optionally be used: salts of the active substances with pharmaceutically acceptable acids or bases, and also solvates, in particular hydrates, of the active substances or of their salts.
Use in combination means either that nifurtimox and the second active substance, in particular a cyclodepsipeptide, can be employed separately or staggered. In this case, nifurtimox and the second active substance are formulated as a separate pharmaceutical.
The simultaneous use is also feasible. According to a use form which is suitable for this case, the active substances of the combination are formulated together in one composition.
Ready-to-use preparations usually contain the active substance in question in concentrations of 10 ppm to 20% by weight, preferably from 0.1 to 10% by weight.
Preparations which are diluted prior to use contain the active substance in question in concentrations of from 0.5 to 90% by weight, preferably from 5 to 50% by weight. In concentrated solutions for metering into the drinking water, the active substance in question is present for example in concentrations of from 0.5 to 20% by weight, preferably 1 to 15% by weight, especially preferably 2 to 10% by weight.
In general, it has proved advantageous to administer amounts of from approximately 0.05 to approximately 400 mg, preferably from 0.1 to 200 mg, of active substance per kg body weight per day in order to achieve effective results.
In the mixture with other coccidiostats, antibiotics or anthelmintics, the active substances according to the invention are present in the ratio 1 to 0.01-50 up to 1 to 1-50.
The active substances can also be administered together with the animals' feed or drinking water.
Feed and foodstuffs contain 0.005 to 1000 ppm, preferably 0.05 to 500 ppm, of the active substance in combination with a suitable edible material.
Such a feed and foodstuff can be used both for therapeutic and for prophylactic purposes.
A disinfectant may be employed to complement the nifurtimox. The disinfectant is used to disinfect the locations where the animals (or the humans) are during the treatment. The disinfectant takes care of the elimination of the parasitic persistent stages, preferably by destroying the cyst forms which are excreted, and thereby prevents reinfection after the end of the treatment. The disinfectant can therefore already be employed before the treatment with nifurtimox; as a rule, however, it is better to employ it at the same time, as, or at least before finishing, the treatment with nifurtimox.
Examples of disinfectants are those based on biocidal phenols and/or phenol derivatives. Biocidal phenols are understood as meaning those phenol compounds which bear a free OH group and have a biocidal activity. These phenols can bear further ring substituents such as, for example, halogens, in particular chlorine, C1-6-alkyl, C3-6-cycloalkyl, phenyl, chlorophenyl, benzyl and/or chlorobenzyl.
Examples of non-chlorinated biocidal phenols are; 2-methylphenol, 3-methylphenol, 4-methylphenol, 4-ethylphenol, 2,4-dimethylphenol, 2,5-dimethylphenol, 3,4-dimethylphenol, 2,6-dimethylphenol, 4-n-propyl phenol, 4-n-butylphenol, 4-n-amylphenol, 4-n-hexylphenol, thymol (5-methyl-2-isopropylphenol), 2-phenylphenol, 4-phenylphenol, 2-benzylphenol. A non-chlorinated biocidal phenol which is preferably employed is 2-phenylphenol.
Examples of chlorinated biocidal phenols are 4-chloro-3-methylphenol (PCMC, p-chloro-m-cresol), 4-chloro-3-ethylphenol, 2-n-amyl-4-chlorophenol, 2-n-hexyl-4-chlorophenol, 2-cyclohexyl-4-chlorophenol, 4-chloro-3,5-xylenol (PCMX, p-chloro-m-xylenol), 2,4-dichloro-3,5-xylenol (DCMX, dichloro-p-xylenol), 4-chloro-2-phenylphenol, 2-benzyl-4-chlorophenol, benzyl-4-chloro-m-cresol, 4-chlorobenzyldichloro-m-cresol. Preferred chlorinated biocidal phenols are 2-benzyl-4-chlorophenol, 4-chloro-3,5-xylenol, 2,4-dichloro-3,5-xylenol and, in particular, 4-chloro-3-methylphenol.
In the present context, phenol derivatives are understood as meaning phenol-derived compounds whose OH group is derivatized, so that they do not contain any free OH groups. They are preferably phenol ethers, in particular those with aliphatic alcohols having 1 to 6 carbon atoms. Phenoxyethanol may be mentioned by way of preferred example.
It is preferred to employ the disinfectants described in WO 2007/009606, which contain biocides and a keratolytic agent. Suitable biocides or biocide combinations and suitable keratolytic agents are described in detail in WO 2007/009606, to which document express reference is made.


EXAMPLES
Formulation Examples
Example 1
Liquid Formulation
Suspensions in 100 ml glycerine formal/glycerine polyethylene glycol ricinoleate (Cremophor® EL)/water in the mixing ratio of 1:10 together with:

    
    
        500 mg nifurtimox
        1000 mg nifurtimox
    
    


Example 2
Liquid Formulation
Suspensions in 100 ml Cremophor® EL/water in the mixing ratio 1:5 together with

    
    
        500 mg nifurtimox
        1000 mg nifurtimox
    
    


Example 3
Solid Formulation
The active substances in the amounts detailed hereinbelow are filled into a gelatine capsule in the form of a powder:

    
    
        250 mg nifurtimox
    
    


Example 4
Tablet
nifurtimox tablets are known and commercially available as a pharmaceutical for example under the trade name Lampit®.
Biological Examples
Example 1
Beagle puppies aged 10-11 weeks which had 11 days to settle in the animal centre before being infected were infected orally with 50 000 Giardia duodenalis cysts. The cysts for the infection were obtained with the aid of a sucrose gradient from the faeces of dogs which excreted Giardia cysts and stored at 4 degrees centigrade in Bacto-Casitone medium for no longer than 2 weeks. From day 10 after the infection, the puppies were kept in individual cages in order to collect the daily total faeces for each individual. The quantitative determination of the cyst excretion was performed in the 4 days prior to treatment (day −3 to 0), and the puppies were divided randomly into two groups, taking into consideration the cyst excretion. On day 0, the 7 puppies of the treatment group were treated once with an oral dose of 50 mg/kg nifurtimox (Lampit®), while the 6 dogs of the control group remained untreated. The quantitative determination of the cyst excretion was continued from day 1 to day 8 after the treatment.
Results: The activity was calculated using the following formula:




  
    Activity
    ⁢
    
      
    
    ⁢
    %
  
  =
  
    
      
        
          
            
              
                number
                ⁢
                
                  
                
                ⁢
                of
                ⁢
                
                  
                
                ⁢
                cysts
                ⁢
                
                  
                
                ⁢
                in
                ⁢
                
                  
                
                ⁢
                the
                ⁢
                
                  
                
                ⁢
                control
                ⁢
                
                  
                
                ⁢
                group
              
              -
            
          
        
        
          
            
              number
              ⁢
              
                
              
              ⁢
              of
              ⁢
              
                
              
              ⁢
              cysts
              ⁢
              
                
              
              ⁢
              in
              ⁢
              
                
              
              ⁢
              the
              ⁢
              
                
              
              ⁢
              treatment
              ⁢
              
                
              
              ⁢
              group
            
          
        
      
      
        number
        ⁢
        
          
        
        ⁢
        of
        ⁢
        
          
        
        ⁢
        cysts
        ⁢
        
          
        
        ⁢
        in
        ⁢
        
          
        
        ⁢
        the
        ⁢
        
          
        
        ⁢
        control
        ⁢
        
          
        
        ⁢
        group
      
    
    ×
    100
  




The calculated activity upon a single nifurtimox dose was 90.4% (see Table 1).
Method: The quantitative determination of the cyst excretion was performed using a modified version of Hewlett (18): 4 g faeces were dissolved in 100 ml of water, sieved and allowed to sediment. The sediment was applied to a 1 M sucrose gradient (specific gravity 1.13), and the cysts, which were concentrated at the sucrose/water boundary layer after the centrifugation were pipetted off. After a wash step followed by centrifugation, the cysts in the pellet were counted. To this end, an aliquot of the pellet was counted under the microscope, and the number of cysts per g faeces was calculated.







TABLE 1





Giardia cyst excretion before and after treatment with nifurtimox



























Dog
D−3
D−2
D−1
D0
D1
D2
D3
D4
D5
D6
D7
D8










50 mg/kg nifurtimox on day D0



















9048
22402
186750
189275
19681
0
0
0
424
0
0
191
1621


9028
5259
45672
45725
16419
2636
180
224
1451
1318
4102
4615
1768


8343
5339
28322
26163
13644
2391
0
0
193
153
6315
223
508


8329
29625
907
1306
4397
504
0
0
590
1700
3693
8881
3294


9040
1063
923
14238
8456
4928
0
0
0
1094
2000
431
517


9038
1385
5897
2264
0
152
0
0
0
0
1201
1873
14181


9020
3263
905
788
375
0
0
0
652
137
353
608
0


Σ
9762
38482
39966
8996
1516
26
32
473
629
2523
2403
3127







Infected, untreated control



















9008
65325
41925
368
0
450
179
1183
3288
4747
14232
22237
3684


8341
21150
44988
35525
3138
1332
806
23399
17739
27253
9321
2660
12901


8309
7144
34613
33688
4531
25050
13238
5547
26106
52000
5125
47365
47999


8327
21250
21485
1350
3991
5383
4520
3529
17355
6145
14298
25331
110846


8313
2975
3185
8168
1209
609
6133
8438
6739
18113
4027
7103
2645


9026
945
2813
1723
2038
3544
3366
20163
11291
6719
4621
5867
5621


Σ
19798
24835
13470
2485
6061
4707
10377
13753
19163
8604
184427
30616













Σ Giardia cyst excretion













Treatment
Day −3 to 0
Day 1 to 8
Activity







50 mg/kg
24302
1341
90.4%



nifurtimox



Infected, untreated
15147
13963
—



control







D−3 to D−1: Days before the treatment



D0: Day of treatment



D1 to D8: Days after the treatment






Example 2
Beagle puppies aged 11-15 weeks which had at least 2 weeks to settle in the animal centre before being infected were infected orally with 50 000 Giardia duodenalis cysts before the beginning of the study. The cysts for the infection were obtained with the aid of a sucrose gradient from the faeces of dogs which excreted Giardia cysts and stored at 4 degrees centigrade in Bacto-Casitone medium for no longer than 2 weeks. 18 puppies which excreted Giardia cysts were included in the study and kept in individual cages in order to collect the daily total faeces. The quantitative determination of the cyst excretion was performed as an experiment 145.717, with the modification that the aliquot of the pellet was counted under the microscope with the aid of a Fuchs-Rosenthal hematocytometer. The quantitative determination of the cyst excretion was performed for 4 days before the treatment (day −3 to 0), and the puppies were divided randomly into three groups, taking into consideration the cyst excretion. On three successive subsequent days (day 0, 1 and 2), the 6 puppies of treatment group 1 were treated in the morning with an oral dose of 50 mg/kg nifurtimox (Lampit®), while the dogs of treatment group 2 were treated on these three days in the morning with an oral dose of 50 mg/kg fenbendazole (fenbendazole tablets). The 6 dogs of the control group remained untreated. The quantitative determination of the cyst excretion was continued from day 1 to day 8 after the treatment.
Results: The calculated activity of nifurtimox was 98.6%, while the activity of fenbendazole was 48.3% (see Table 2).







TABLE 2





Giardia cyst excretion before and after treatment with nifurtimox in comparison with


the treatment with fenbendazole.



























Dog
D−3
D−2
D−1
D0
D1
D2
D3
D4
D5
D6
D7
D8










50 mg/kg nifurtimox on days D0, D1 and D2



















9300
63463
79689
91293
103442
1261
527
0
0
0
0
0
903


0136
102900
68914
59273
112084
2000
0
0
622
1299
93
0
0


0116
57571
10685
25515
60420
809
741
0
0
229
0
0
517


8553
40909
8278
3472
675
187
0
0
185
0
98
0
0


8531
4891
1618
37203
89880
974
0
0
0
0
0
87
975


0134
28773
133
8528
86
0
0
0
0
2299
1842
237
0


Σ
49751
28220
37547
61098
872
211
0
135
638
339
54
399







50 mg/kg fenbendazole on days D0, D1 and D2



















0117
18781
47754
243143
49400
67200
0
67109
49423
3116
4635
17474
0


9320
60193
23808
56014
28559
14596
5980
7043
652
18725
7546
20780
5555


8555
44218
26526
2349
639
872
0
961
439
4432
5594
260
5968


8543
34119
18113
16328
2719
12488
3386
3075
12038
0
3691
18056
10875


0135
20463
7230
14744
17037
6178
490
0
0
0
0
251
0


9328
2003
10109
21360
23290
723
552
5388
14133
19057
11495
20657
6370


Σ
29963
22257
58990
20274
17010
1735
13929
12781
7555
5494
12913
4795







Infected, untreated control



















0121
112757
27324
121092
108868
153336
64620
6127
190
6879
85408
73978
50256


0138
22125
65547
60200
26964
22234
855
17893
8138
13204
3681
439
1470


9332
22346
34475
42076
24466
24360
19145
12575
1455
5712
16122
21440
12563


8529
8884
49213
12881
32105
71378
1139
6409
4739
5297
23725
11626
2835


9330
18829
4711
22120
2476
1987
0
246
2492
4472
602
2052
813


0137
4623
12238
14406
14328
2134
10156
16756
0
8170
104020
79097
55935


Σ
31594
32251
45463
34868
45905
15986
10001
2836
7289
38926
31439
20645













Σ Giardia cyst excretion













Treatment
Day: −3 to 0
Day 3 to 8
Activity







50 mg/kg
44154
261
98.6%



nifurtimox



50 mg/kg
32871
9578
48.3%



fenbendazole



Infected, untreated
36044
18523
—



control







D−3 to D−1: Days before the treatment



D0, D1, D2: Days of treatment



D3 to D8: Days after the treatment






References

    (1) Raether w., Hänel H. (2003): Nitroheterocyclic drugs with broad spectrum activity Parasitol Res. 90:S19-S39.
    (2) Harder A. Greif G, Haberkorn A. (2001a): Chemotherapeutic approaches to protozoa: Haemosporina—current level of knowledge and outlook.
    (3) Harder A, Greif G., Haberkorn A. (2001b): Chemotherapeutic approaches to protozoa: Giardia, Trichomonas and Entamoeba—current level of knowledge and outlook.
    (4) Greif G, Harder A, Haberkorn A (2001): chemotherapeutic approaches to protozoa: Coccidia—current level of knowledge and outlook.
    (5) Harder A, Greif G., Haberkorn A (2001c): Chemotherapeutic approaches to protozoa: Kinetoplastida—current level of knowledge and outlook. Parasitol Res 87:778-780.
    (6) Adam R. D. (2001): Biology of Giardia lamblia. Clinical Microbiology Reviews, July: 447-475.
    (7) Marshall M M, Naumovitz D., Ortega Y., Sterling C R. (1997): Waterborne protozoan Pathogens. Clinical Microbiology Reviews January:67-85.
    (8) Roxström-Lindquist, K. Palm D., Reiner D., Ringqvist E., Svärd S G. (2006): Giardia immunity—an update. Trends in Parasitology Vo. 22(1):26-31.
    (9) Beckmann L. (2003): Mucosal defenses against Giardia. Parasite Immunology 25:259-270.
    (10) Hülsmeier A. J., Köhler P. (2005): Giardia duodenalis: direct experimental evidence for the absence of a glycosylphosphatidylinositol anchor in a variant surface protein. Experimental Parasitology 109:49-52.
    (11) Kirkpatrick, C E, Farrell J P (1984): Feline giardiasis: observations on natural and induced infections. Amer. J. Vet. Res. 45:2182-2188.
    (12) Zimmer J F, Burrington D B (1986): Comparison of four protocols for the treatment of canine giardiasis. J. Amer. Anim. Hosp. Ass. 22:168-172.
    (13) Abbitt B, Huey R L, Eugster A K, Syler J. (1986): Treatment of giardiasis in adult greyhounds, using ipronidazole-medicated water. J. Amer. Vet. Med. Ass. 188:67-69.
    (14) Wright J M., Dunn L. A., Uperoft P., Uperoft J. A. (2003): Efficacy of antigiardial drugs. Expert Opin. Drug Saf. 2(6):529-541.
    (15) Escobedo A. A & Cimerman S. (2007): Giardiasis: a pharmacotherapy review. Expert Opin. Pharmacother. 8(12):1885-1902.
    (16) Harder A. et al. (2003) Cyclooctadepsipeptides—an anthelmintically active class of compounds exhibiting a novel mode of action. Int. J. Antimicrobial Agents. 22: 318-331.
    (17) Mehlhorn (ed) (2001) Giardiasis, Man; Encyclopedic Reference of Parasitology, Diseases, treatment, Therapy, Second Edition, Springer-Verlag, pp. 234-235.
    (18) Hewlett, E. L., Andrews, J. S. Jr., Ruffier, J., Schaefer III, F. W. (1982): Experimental infection of mongrel dogs with Giardia lamblia cysts and cultured trophozoites

In: The Journal of infectious diseases, Vol. 145, No. 1, pp 89-93

## Claims

1. A pharmaceutical formulation comprising nifurtimox and an anthelmintic comprising a cyclooctadepsipeptide.

2. A method of treating a disease caused by a Giardia species in an animal comprising administering to the animal in need thereof a pharmaceutical formulation comprising nifurtimox.

3. The method of claim 2, wherein the Giardia species is Giardia lamblia.

4. The method of claim 2, wherein the pharmaceutical formulation further comprises an anthelmintic.

5. The method of claim 4, wherein the anthelmintic comprises a cyclooctadepsipeptide.

6. The method of claim 5, wherein the cyclooctadepsipeptide comprises a compound selected from the group consisting of PF1022, PF1022A, PF1022-221, salts thereof, and solvates thereof.

7. The method of claim 2, wherein the pharmaceutical formulation comprising nifurtimox is administered orally to the animal.

8. The method of claim 7, wherein the pharmaceutical formulation comprising nifurtimox is a tablet.

9. The method of claim 7, wherein the pharmaceutical formulation comprising nifurtimox is administered to the animal by metering into the animal's feed or drinking water.

10. The method of claim 2, further comprising applying a disinfectant to a location where infectious feces is excreted by the animal during treatment.

11. A method of treating a disease caused by a Giardia species and a nematode infection in an animal comprising administering to the animal in need thereof a pharmaceutical composition comprising nifurtimox and an anthelmintic.

12. The method of claim 11, wherein the Giardia species is Giardia lamblia.

13. The method of claim 11, wherein the anthelmintic comprises a cyclooctadepsipeptide.

14. The method of claim 13, wherein the cyclooctadepsipeptide comprises a compound selected from the group consisting of PF1022, PF1022A, PF1022-221, salts thereof, and solvates thereof.

15. The method of claim 11, wherein the pharmaceutical formulation comprising nifurtimox is administered orally to the animal.

16. The method of claim 15, wherein the pharmaceutical formulation comprising nifurtimox is a tablet.

17. The method of claim 11, wherein the pharmaceutical formulation comprising nifurtimox is administered to the animal by metering into the animal's feed or drinking water.

18. The method of claim 11, further comprising applying a disinfectant to a location where infectious feces is excreted by the animal during treatment.

19. The pharmaceutical formulation of claim 1, wherein the cyclooctadepsipeptide comprises a compound selected from the group consisting of PF1022, PF1022A, PF1022-221, salts thereof, and solvates thereof.

20. The pharmaceutical formulation of claim 1, wherein the cyclooctadepsipeptide is emodepside, salt thereof, or solvate thereof.